AJR 2000; 175:1600
© American Roentgen Ray Society
Trauma Cases from Harborview Medical Center |
Blunt Duodenal Rupture
Complementary Roles of Sonography and CT
Elaine Yutan1,
Gayle M. Waitches2 and
Riyad Karmy-Jones1
1
Department of Surgery, Harboriview Medical Center, University of Washington
School of Medicine, Box 359728, 325 Ninth Ave., Seattle, WA 98104.
2
Department of Radiology, Harborview Medical Center, University of Washington
School of Medicine, Seattle, WA 98104.
Received May 22, 2000;
accepted after revision July 10, 2000.
This is another in the continuing series on radiology in trauma cases from
the Harborview Medical Center. Editors: Fred A. Mann, Eric J. Stern, and
Alexander B. Baxter.
Address correspondence to F. A. Mann.
Introduction
A 19-year-old, nonrestrained male driver was admitted to the hospital after
a high-speed rollover motor vehicle collision. At admission, he was awake and
alert with stable vital signs and complained of diffuse abdominal pain. Most
of his pain was localized over an abrasion on the right upper quadrant.
Focused abdominal sonography for trauma showed a small amount of fluid in
Morison's pouch and in the right paracolic gutter. Because of the free
intraperitoneal fluid and suspicion of intraabdominal injury, IV
contrast—enhanced helical CT of the abdomen without oral contrast
material was performed, which showed duodenal rupture and liver laceration
(Fig.
1A,1B).
At laparotomy, a laceration involving more than 50% of the duodenal
circumference was found along the lateral border of the duodenum at the
junction of the descending (zone 2) and horizontal (zone 3) segments. The
liver laceration was not actively bleeding. The duodenal laceration was
closed.
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Fig. 1A. —19-year-old man after motor vehicle collision. IV
contrast—enhanced helical CT scan of abdomen reveals disruption of
lateral wall of junction of second and third portions of duodenum, consistent
with mural laceration. Note combination of accompanying duodenal wall
thickening (arrowheads) and intra- and extraluminal fluid
(arrow).
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Fig. 1B. —19-year-old man after motor vehicle collision. IV
contrast—enhanced helical CT scan of abdomen reveals linear
low-attenuation laceration (arrowheads) in right lobe of liver,
extending to gallbladder fossa.
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Duodenal rupture occurs in 2-20% of patients with blunt abdominal injury
and often occurs after blows to the upper abdomen or abdominal compression
from high-riding seat belts. Forty percent of patients with duodenal injuries
have other concomitant surgically important intraabdominal injuries, such as
hepatic (38%) or pancreatic (28%) injuries
[1].
In patients with blunt abdominal injury without physical findings that
suggest the need for emergent laparotomy, focused abdominal sonography
provides an alternative to diagnostic peritoneal lavage. Focused abdominal
sonography is faster and less invasive than diagnostic peritoneal lavage and
can occasionally reveal injuries in the retroperitoneum
[2]. Focused abdominal
sonography that reveals free fluid suggests hemoperitoneum or bowel injury,
which requires abdominal CT or laparotomy. We believe there is little need for
immediate diagnostic peritoneal lavage after abdominal sonography that reveals
abnormal findings. Although somewhat controversial, IV contrast—enhanced
abdominal CT without oral contrast medium facilitates patient scheduling by
diminishing patient transit time and dependence on patient cooperation and
will not obscure important findings such as bowel hemorrhage or appendicolith
[3]. Deferring the
administration of oral contrast material has not been convincingly shown to
decrease overall diagnostic sensitivity for surgically important injuries to
intraabdominal contents or the retroperitoneum
[4]. CT findings of free
intraabdominal fluid without solid-organ injury should prompt diagnostic
peritoneal lavage or laparotomy to exclude hollow viscus injuries.
Diagnostic peritoneal lavage or focused abdominal sonography may fail to
reveal slightly abnormal findings; therefore, a high degree of clinical
suspicion of further injury is required to prompt CT or laparotomy before the
onset of sepsis [5,
6].
This case illustrates how the sonographic finding of free intraperitoneal
fluid prompted further examination with CT, which revealed retroperitoneal and
peritoneal injuries. In patients with duodenal trauma, there is an increased
incidence of pancreatic injuries requiring complex repairs, which are
associated with increased morbidity and mortality. Early diagnosis allows
greater opportunity for definitive repair at the initial surgery and lowers
the risks of sepsis, coagulopathy, and pancreatic necrosis.
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Introduction
References
